Sugammadex has been approved for reversal of neuromuscular blockade by vecuronium and rocuronium in adults undergoing surgery. Although widely used in the operating room, sugammadex has not been ...investigated in the intensive care unit setting. This study aimed to evaluate the use of sugammadex in critically ill patients with a focus on known drug-related adverse reactions. In this single-center, retrospective, observational study, 91 critically ill patients who were administered sugammadex while in the ICU were evaluated. Electronic health records were reviewed, and baseline data, as well as indication and incidence of complications possibly related to sugammadex, were retrospectively collected. The most common procedures requiring neuromuscular blockade followed by reversal with sugammadex were bronchoscopy, percutaneous dilatative tracheostomy, and percutaneous endoscopic gastrostomy. Within 2 h following administration of sugammadex, skin rash and use of antihistamines were reported in 4 patients (4.4%) in total; bradycardia was observed in 9 patients (9.9%), and respiratory adverse events were described in 3 patients (3.3%). New-onset bleeding up to 24 h after sugammadex was reported in 7 patients (7.7%), 3of whom received transfusions of packed red blood cells. Sugammadex was well tolerated in critically ill patients and could be considered for reversal of neuromuscular blockade in this population. Larger prospective studies are required to determine the safety profile and evaluate the potential benefit and indications of sugammadex in the critical care setting.
Background
Duration of invasive mechanical ventilation (IMV) prior to extracorporeal membrane oxygenation (ECMO) affects outcome in acute respiratory distress syndrome (ARDS). In coronavirus disease ...2019 (COVID-19) related ARDS, the role of pre-ECMO IMV duration is unclear. This single-centre, retrospective study included critically ill adults treated with ECMO due to severe COVID-19-related ARDS between 01/2020 and 05/2021. The primary objective was to determine whether duration of IMV prior to ECMO cannulation influenced ICU mortality.
Results
During the study period, 101 patients (mean age 56 SD ± 10 years; 70 69% men; median RESP score 2 IQR 1–4) were treated with ECMO for COVID-19. Sixty patients (59%) survived to ICU discharge. Median ICU length of stay was 31 IQR 20.7–51 days, median ECMO duration was 16.4 IQR 8.7–27.7 days, and median time from intubation to ECMO start was 7.7 IQR 3.6–12.5 days. Fifty-three (52%) patients had a pre-ECMO IMV duration of > 7 days. Pre-ECMO IMV duration had no effect on survival (
p
= 0.95). No significant difference in survival was found when patients with a pre-ECMO IMV duration of < 7 days (< 10 days) were compared to ≥ 7 days (≥ 10 days) (
p
= 0.59 and
p
= 1.0).
Conclusions
The role of prolonged pre-ECMO IMV duration as a contraindication for ECMO in patients with COVID-19-related ARDS should be scrutinised. Evaluation for ECMO should be assessed on an individual and patient-centred basis.
Background During the COVID-19 pandemic, a variety of clinical decision support systems (CDSS) were developed to aid patient triage. However, research focusing on the interaction between decision ...support systems and human experts is lacking. Methods Thirty-two physicians were recruited to rate the survival probability of 59 critically ill patients by means of chart review. Subsequently, one of two artificial intelligence systems advised the physician of a computed survival probability. However, only one of these systems explained the reasons behind its decision-making. In the third step, physicians reviewed the chart once again to determine the final survival probability rating. We hypothesized that an explaining system would exhibit a higher impact on the physicians' second rating (i.e., higher weight-on-advice). Results The survival probability rating given by the physician after receiving advice from the clinical decision support system was a median of 4 percentage points closer to the advice than the initial rating. Weight-on-advice was not significantly different (p = 0.115) between the two systems (with vs without explanation for its decision). Additionally, weight-on-advice showed no difference according to time of day or between board-qualified and not yet board-qualified physicians. Self-reported post-experiment overall trust was awarded a median of 4 out of 10 points. When asked after the conclusion of the experiment, overall trust was 5.5/10 (non-explaining median 4 (IQR 3.5-5.5), explaining median 7 (IQR 5.5-7.5), p = 0.007). Conclusions Although overall trust in the models was low, the median (IQR) weight-on-advice was high (0.33 (0.0-0.56)) and in line with published literature on expert advice. In contrast to the hypothesis, weight-on-advice was comparable between the explaining and non-explaining systems. In 30% of cases, weight-on-advice was 0, meaning the physician did not change their rating. The median of the remaining weight-on-advice values was 50%, suggesting that physicians either dismissed the recommendation or employed a "meeting halfway" approach. Newer technologies, such as clinical reasoning systems, may be able to augment the decision process rather than simply presenting unexplained bias. Keywords: Triage, Decision process, Clinical decision support systems, Machine learning, Human-computer interaction
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Multiple risk factors for postoperative nausea and vomiting (PONV)-a very distressing and outcome-related complication-have been identified, including female sex, absence of a history of smoking, ...history of PONV, and postoperative opioid use. Evidence of association of intraoperative hypotension with PONV is contradictory. A retrospective analysis of the perioperative documentation of 38,577 surgeries was conducted. The associations between different characterizations of intraoperative hypotension and PONV in the postoperative care unit (PACU) were investigated. First, the relationship between different characterizations of intraoperative hypotension with regard to PONV in the PACU was investigated. Secondly, the performance of the optimal characterization was assessed in an independent dataset derived via random split. The vast majority of characterizations showed an association of hypotension with the incidence of PONV in the PACU. In a multivariable regression, time with a MAP under 50 mmHg showed the strongest association with PONV in terms of the cross-validated Brier score. The adjusted odds for PONV in the PACU were estimated to be 1.34 times higher (95% CI: 1.33-1.35) when a MAP was under 50 mmHg for at least 1.8 min than when a MAP remained above 50 mmHg. The finding indicates that intraoperative hypotension may yet be another risk factor for PONV and therefore emphasizes the importance of intraoperative blood pressure management not only in patients at risk for cardiovascular complications but also in young and healthy patients at risk of PONV.
Bystander-initiated basic life support (BLS) for the treatment of prehospital cardiac arrest increases survival but is frequently not performed due to fear and a lack of knowledge. A simple flowchart ...can improve motivation and the quality of performance. Furthermore, guidelines do recommend a chest compression (CC)-only algorithm for dispatcher-assisted bystander resuscitation, which may lead to increased fatigue and a loss of compression depth. Consequently, we wanted to test the hypothesis that CCs are more correctly delivered in a flowchart-assisted standard resuscitation algorithm than in a CC-only algorithm.
With the use of a manikin model, 84 laypersons were randomized to perform either flowchart-assisted standard resuscitation or CC-only resuscitation for 5min. The primary outcome was the total number of CCs.
The total number of correct CCs did not significantly differ between the CC-only group and the standard group (63 ±81 vs. 79 ±86; p = 0.394; 95% CI of difference: 21-53). The total hand-off time was significantly lower in the CC-only group than in the standard BLS group. The relative number of correct CCs (the fraction of the total number of CCs achieving 5-6cm) and the level of exhaustion after BLS did not significantly differ between the groups.
Standard BLS did not lead to an increase in correctly delivered CCs compared to CC-only resuscitation and exhibited significantly more hand-off time. The low rate of CCs in both groups indicates the need for an increased focus on performance during BLS training.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Patients receiving extracorporeal membrane oxygenation (ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for coronavirus disease 2019 (COVID-19) ...patients during ECMO therapy.
We conducted a retrospective analysis of COVID-19 patients requiring venovenous ECMO support at a large tertiary hospital center. Nutrition goals were calculated using 25 kcal/kg body weight (BW)/day. Associations between nutrition support and outcome were evaluated using Kaplan-Meier and multivariable Cox regression analyses.
Overall, 102 patients accounted for a total of 2344 nutrition support days during ECMO therapy. On 40.6% of these days, nutrition goals were met. Undernutrition was found in 40.8%. Mean daily calorie delivery was 73.7% of calculated requirements, mean daily protein delivery was 0.7 g/kg BW/d. Mean energy intake of ≥70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity at ECMO start and body mass index (adjusted hazard ratio: 0.372,
= 0.007).
Patients with a mean energy delivery of ≥70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.
Although prehospital point-of-care ultrasound (POCUS) is gaining in importance, its rapid interpretation remains challenging in prehospital emergency situations. The technical development of remote ...real-time supervision potentially offers the possibility to support emergency medicine providers during prehospital emergency ultrasound. The aim of this study was to assess the feasibility of live data transmission and supervision of prehospital POCUS in an urban environment and so to improve patients' safety.
Emergency doctors with moderate ultrasound experience performed prehospital POCUS in emergency cases (n = 24) such as trauma, acute dyspnea or cardiac shock using the portable ultrasound device Lumify™. The ultrasound examination was remotely transmitted to an emergency ultrasound expert in the clinic for real-time supervision via a secure video and audio connection. Technical feasibility as well as quality of communication and live stream were analysed.
Prehospital POCUS with remote real-time supervision was successfully performed in 17 patients (71%). In 3 cases, the expert was not available on time and in 1 case remote data transmission was not possible due to connection problems. In 3 cases tele-supervision was restricted to video only and no verbal communication was possible via the device itself due to power saving mode of the tablet.
Remote real-time supervision of prehospital POCUS in an urban environment is feasible most of the time with excellent image and communication quality.
ClinicalTrials Number NCT04612816.
Prolonged critical illness is often accompanied by an impairment of adrenal function, which has been frequently related to conditions complicating patient management. The presumed connection between ...hypoxia and the pathogenesis of this critical- illness- related corticosteroid insufficiency (CIRCI) might play an important role in patients with severe acute respiratory distress syndrome (ARDS). Since extracorporeal membrane oxygenation (ECMO) is frequently used in ARDS, but data on CIRCI during this condition are scarce, this study reports the behaviour of adrenal function parameters during oxygenation support with veno-venous (vv)ECMO in coronavirus disease 2019 (COVID-19) ARDS.
A total of 11 patients undergoing vvECMO due to COVID-19 ARDS at the Medical University of Vienna, who received no concurrent corticosteroid therapy, were retrospectively included in this study. We analysed the concentrations of cortisol, aldosterone, and angiotensin (Ang) metabolites (Ang I-IV, Ang 1-7, and Ang 1-5) in serum via liquid chromatography/tandem mass spectrometry before, after 1 day, 1 week, and 2 weeks during vvECMO support and conducted correlation analyses between cortisol and parameters of disease severity.
Cortisol concentrations appeared to be lowest after initiation of ECMO and progressively increased throughout the study period. Higher concentrations were related to disease severity and correlated markedly with interleukin-6, procalcitonin, pH, base excess, and albumin during the first day of ECMO. Fair correlations during the first day could be observed with calcium, duration of critical illness, and ECMO gas flow. Angiotensin metabolite concentrations were available in a subset of patients and indicated a more homogenous aldosterone response to plasma renin activity after 1 week of ECMO support.
Oxygenation support through vvECMO may lead to a partial recovery of adrenal function over time. In homogenous patient collectives, this novel approach might help to further determine the importance of adrenal stress response in ECMO and the influence of oxygenation support on CIRCI.
Aims Due to time-critical decision-making, physical strain and the uncontrolled environment, prehospital emergency management is frequently associated with high levels of stress in medical personnel. ...Stress has been known to cause ischemia like changes in electrocardiograms (ECGs), including arrhythmias and deviations in ST-T segments. There is a lack of knowledge regarding the occurrence of changes in ST-T segments in prehospital emergency physicians. We hypothesized that ST-T segment deviations occur in prehospital emergency physicians in the field. Methods In this prospective observational trial, ST-T segments of emergency physicians were recorded using 12-lead Holter ECGs. The primary outcome parameter was defined as the incidence of ST-T segment changes greater than 0.1 mV in two corresponding leads for more than 30 s per 100 rescue missions. The secondary outcomes included T-wave inversions and ST-segment changes shorter than 30 s or smaller than 0.1 mV. Surrogate parameters of stress were measured using the NASA-Task Load Index and cognitive appraisal, and their correlation with ST-T segment changes were also assessed. Results Data from 20 physicians in 36 shifts (18 days, 18 nights) including 208 missions were analysed. Seventy percent of previously healthy emergency physicians had at least one ECG abnormality; the mean duration of these changes was 30 s. Significantly more missions with ECG changes were found during night than day shifts (39 vs. 17%, p < 0.001). Forty-nine ECG changes occurred between missions. No ST-T segment changes > 30 s and > 0.1 mV were found. Two ST-T segment changes < 30 s or < 0.1 mV (each during missions) and 122 episodes of T-wave inversions (74 during missions) were identified. ECG changes were found to be associated with alarms when asleep and NASA task load index. Conclusion ECG changes are frequent and occur in most healthy prehospital emergency physicians. Even when occurring for less than 30 s, such changes are important signs for high levels of stress. The long-term impact of these changes needs further investigation. Trial registration The trial was registered at ClinicalTrials.gov (NCT04003883) on 1.7.2019: Keywords: ST-T segment, Stress, Emergency, Critical care, Prehospital
Early during the course of the ongoing COVID-19 pandemic, reports suggested alarmingly high incidences for thromboembolic events in critically ill patients with COVID-19. However, the clinical ...relevance of these events was not reported in several studies. Additionally, more recent research showed contradictory results and suggested substantially lower rates of venous thromboembolism. Thus, the aim of the present study was to summarize evidence on the incidence of clinically relevant venous thromboembolism (VTE)-defined as VTE excluding isolated subsegmental pulmonary embolism (PE) and distal deep vein thrombosis (DVT)-in adult critically ill patients with COVID-19.
We performed a systematic review of studies reporting the incidence of clinically relevant PE and/or DVT in critically ill patients with COVID-19. Scientific reports published in the English language between January and October 2020 were included. We conducted a random-effects model meta-analysis to calculate incidence estimates of clinically relevant VTE and bleeding events. We also performed exploratory meta-regression and subgroup analyses of different diagnostic approaches and additional factors that possibly influenced the incidence of these outcomes.
Fifty-four articles (5,400 patients) fulfilled the predefined inclusion criteria, of which 41 had a high risk of bias. The majority of included patients were male, > 60 years, and overweight. Twenty-one studies reported the use of prophylactic doses of heparin. Pooled incidences for clinically relevant PE were estimated at 8% (95% CI, 4-11%), for proximal DVT at 14% (95% CI, 9-20%), and-after exclusion of studies with a high risk of bias-for the composite outcome of VTE at 18% (95% CI, 13-24%). Clinically relevant bleeding occurred at a rate of 6% (95% CI, 2-9%).
We summarized currently available data on the rate of clinically relevant VTE in critically ill patients with COVID-19. Pooled incidence estimates were lower than those reported by previous review articles. In the absence of evidence-based anticoagulation guidelines for critically ill patients with COVID-19, the results of our study provide clinically important information for an individual risk-benefit assessment in this context.
The study protocol was prospectively registered in PROSPERO on June 22, 2020 (CRD42020193353; https://www.crd.york.ac.uk/prospero).
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